A scribe documents a complete physician office visit note that has not been authenticated by the physician. Can the coder rely on that note for code assignment yet?
Select an answer to reveal the explanation.
Short Explanation
A scribe can type fast, but the physician still has to own the note. Without authentication, that documentation is not ready for coding or billing. Wait for the signature—then code.
Full Explanation
Documentation used to support professional-fee code assignment must meet authentication and signature requirements under payer and organizational rules. An unsigned scribe note lacking physician attestation is not yet permissible documentation for coding. Coders should hold claims or queries until the provider authenticates the record according to policy, then assign codes based on the authenticated content.